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Geriatric Nursing 34 (2013) 465e468
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Geriatric Nursing
journal homepage: www.gnjournal .com
Feature Article
Relationship between BMI and physical performance among older adults
Raiana Souza Ferreira a, Raildo da Silva Coqueiro, MS a,*, Aline Rodrigues Barbosa, PhD a,b,Paloma Andrade Pinheiro a,c, Marcos Henrique Fernandes, PhD a,c
aNúcleo de Estudos em Epidemiologia do Envelhecimento (NEPE), Departamento de Saúde, Universidade Estadual do Sudoeste da Bahia, Av. José Moreira Sobrinho, S/N, Jequiezinho,Jequié, BA 45206-190, BrazilbDepartamento de Educação Física, Centro de Desportos, Universidade Federal de Santa Catarina, Florianópolis, Brazilc Programa de Pós-Graduação em Enfermagem e Saúde (PPGES), Departamento de Saúde, Universidade Estadual do Sudoeste da Bahia, Jequié, Brazil
a r t i c l e i n f o
Article history:Received 16 May 2013Received in revised form23 July 2013Accepted 25 July 2013Available online 28 August 2013
Keywords:Body mass indexNutritional statusPhysical fitnessTime and motion studiesHealth of the elderly
Author bio-line: Raiana Souza Ferreira, Bachelor inNúcleo de Estudos em Epidemiologia do EnvelheciEstadual do Sudoeste da Bahia (UESB), Brazil. RaProfessor Assistente in the Departamento de Saúde, RBrazil. Aline Rodrigues Barbosa, PhD, Researcher collaAdjunto in the Centro de Desportos, Universidade FedPaloma Andrade Pinheiro, Master’s degree StudenMember from NEPE, UESB, Brazil. Marcos HenriquAdjunto in the Departamento de Saúde, Researcher fr* Corresponding author. Tel.: þ55 73 3528 9726.
E-mail addresses: [email protected], raiconSilva Coqueiro).
0197-4572/$ e see front matter � 2013 Mosby, Inc. Ahttp://dx.doi.org/10.1016/j.gerinurse.2013.07.013
a b s t r a c t
Our objective was to examine the relationship between body mass index (BMI) and physical performancein community-dwelling older adults. This was a descriptive and association study, based on secondarydata derived from a population-based epidemiological research involving 316 older adults. The BMI wasthus classified: <22.0 kg/m2, underweight; 22.0 � BMI � 27.0 kg/m2, adequate; >27.0 kg/m2, overweight.Physical performance was assessed based on “chair stand”, “pick up a pen” and walking tests. Associa-tions between BMI and performance at each test were tested by Cox regression for survival analysis withmultiple modeling adjusted by gender and age, adopting a significance level of 5% (a ¼ 0.05). Individualswith underweight (badjusted ¼ 0.64; p ¼ 0.004), performed poorly in the “chair stand” test whencompared to individuals with adequate weight. The BMI was a predictor of good physical function, withunderweight being more of a limiting factor than overweight.
� 2013 Mosby, Inc. All rights reserved.
Epidemiological studies that used body mass index (BMI),a classic indicator of nutritional status, demonstrate that bothunderweight and overweight coexist in high proportions amongpopulations of older adults.1e3 Considering them as two extremesof the BMI, underweight and overweight pose health risks to olderadults.1,3,4 The former is related to multiple consequences, such aschanges to muscle and body mass, immune dysfunction, anemia,cognitive impairment, wound healing difficulties, slower post-operative recovery and greater risk of institutionalization, hospi-talization and mortality.4e6 Overweight is an independent riskfactor for cardiovascular and pulmonary disease, diabetes, dyslipi-demia, many types of cancer, osteopathy and cognitive and
physiotherapy, member frommento (NEPE), Universidadeildo da Silva Coqueiro, MS,esearcher from NEPE, UESB,borator from NEPE, Professoreral de Santa Catarina, Brazil.t in Enfermagem e Saúde,e Fernandes, PhD, Professorom NEPE, UESB, Brazil.
[email protected] (R. da
ll rights reserved.
psychological problems.7 Both conditions of nutritional inadequacyaffect physical fitness, leading the individual to a condition offragility and subsequent functional dependency and low quality oflife.5
The ability to carry out daily activities in a safe, independentmanner without incurring in excessive fatigue is directly relatedwith good functioning of the musculoskeletal system.8 Therefore,assessing physical performance through tasks that demandmuscular strength and endurance, flexibility, mobility and balanceprovides a diagnosis of the functional health of older adults.8e10 Afew studies using BMI sought to analyze the association betweenunderweight and/or overweight and motor test performance incommunity-dwelling older adults.10e13 The results from thesestudies showed that this association was dependent on gender, agegroup and type of test carried out.11,12 In a recent study involvingindividuals aged 55 or more, performance in a battery of motorsystem tests was independent from BMI.10 It is not yet possible todetermine, based on existing research, whether an inadequate BMIis a predictor of weak physical performance in older adults andwhich disorder, underweight or overweight, impairs the physicalfunction the most.
The purpose of this study was to examine the relationshipbetween BMI and physical performance in community-dwellingolder adults. Specifically we hypothesized that those who wereunderweight would have poorer physical performance in tests of
Table 1Characteristics of the study population. Lafaiete Coutinho, Brazil, 2011.
Variables % Response N %
Age group 99.760e69 years 115 36.570e79 years 106 33.7P80 years 94 29.8
Marital status 100.0Living with partner 179 56.6Single 38 12.0Widower 81 25.6Divorced 18 5.7
Literacy 100.0Yes 105 33.2No 211 66.8
Financial difficulty 97.8Yes 220 71.2No 89 28.8
R.S. Ferreira et al. / Geriatric Nursing 34 (2013) 465e468466
muscle strength/endurance and those whowere overweight wouldshow poorer performance on tests of mobility/flexibility.
Methods
Setting and study population
This was a descriptive and association study, based on se-condary data derived from a cross-sectional, population-basedhousehold survey called “Nutritional status, risk behaviors andhealth conditions of older adults residents of Lafaiete Coutinho,Bahia”. Details about the setting and study population as well asdata collection have already been published.14 In short, a completecensus was conducted in Lafaiete Coutinho (January 2011) for theidentification of older adults (�60 years). The location of the resi-dences was conducted using information from The Family HealthStrategy, a program of primary health care that covers all county. Allresidents (n ¼ 355) in the urban zone were contacted. Of the 355older adults that made up the study population, 316 (89.0%) tookpart in the research: 17 refusals (4.8%) were registered and 22(6.2%) individuals were not located after three household visits onalternate days, and were regarded as losses. The study was carriedout in accordancewith theWorldMedical Association’s Declarationof Helsinki and was approved by the Ethics Committee on HumanResearch.
In the present study, older adults who met any of the exclusioncriteria as described below were not enrolled: individuals whowere unable to understand the test instructions due to cognitiveproblems; those who couldn’t walk or needed help to remainstanding up, who had paralysis of a limb, who used a leg prosthesisor who could not keep their balance were not included in the lowerlimbs test and; those who underwent eye surgery in the past6 weeks did not take the “pick up a pen” test.
Measurements
Physical performance testsA detailed description of the procedures for implementing each
physical performance test was previously published.8 The followingis a brief description. The “chair stand” test assessed the strength/endurance of the lower limbs.15 The participants were invited tocross their arms at chest height and then stand up and sit down onthe chair five times, as quickly as possible, while being timed inseconds (s). Individuals were considered apt to carry out the testwhen concluding it 60 s or less.
The “pick up a pen” test checked mobility/flexibility.16 For thistask, a pen was placed approximately 30 cm from the participant’sfoot, and on the command “go,” the participant had to pick up thepenny from the floor and stand up. Timed from the command “go”until the individual was standing erect with pen in hand. Partici-pants were considered capable of carrying out the test when theyconcluded it without support in 30 s or less.
The walking test checked the ability to move of older adults.15 Inorder to test their walking speed the participants were instructed towalk from one end to the other of a 2.44 m course in their habitualspeed, as if walking on a sidewalk. Participants could use mobilitysupport devices, if necessary, and the course was covered twice andtimed in seconds. The shortest time was considered for the anal-yses. The individual was considered apt to carry through the test ifcapable of concluding it in 60 s or less.
BMI (explanatory variable)Body mass was measured with a portable digital balance
(Zhongshan Camry Eletronic, G-Tech Glass 6, China); the individualwas weighed barefoot and wearing a minimum of clothes. Height
was measured according to the technique by Frisancho,17 usinga portable compact stadiometer (Wiso, China) placed at a suitablelocation according to the manufacturer’s rules. Height measure-ments were taken three times and mean values were used tocalculate body mass index [BMI ¼ body mass (kg)/height2 (m)].
The BMI was thus classified according to the cut-off points ofthe American Academy of Family Physicians et al18 adopted bythe Brazilian System of Surveillance for Food and Nutrition(Portuguese acronym, SISVAN)19: BMI < 22.0 kg/m2, underweight;22.0 � BMI � 27.0 kg/m2, adequate; BMI > 27.0 kg/m2, overweight.
Statistical analyses
The associations between BMI (explanatory variable) andperformance at each physical performance test (dependent vari-ables) were tested with Cox’s regression technique for survivalanalysis with multiple modeling adjusted by gender and age. Thelevel of significance adopted for all analyses was 5% (a ¼ 0.05). Thedata were tabulated and analyzed with statistical program SPSS�
version 16.0.
Results
Study participants amounted to 173 women (54.7%) and 143men (45.3%). Age varied between 60 and 105 years, the mean being74.2 � 9.8 years. The average age of the womenwas 74.9 � 10 years(60e103), whereas for men it was 73.4 � 9.4 years. The othercharacteristics of the studied population are shown in Table 1. Mostindividuals reported living in common law partnership, notknowing how to read or write and having financial difficulties.
Body mass and height measurements were taken from 301individuals. The distribution of the older adults according to BMIwas: underweight 28.9% (n ¼ 87), adequate weight 42.5% (n ¼ 128)and overweight 28.6% (n ¼ 86). Of the 316 individuals interviewed,25 (7.9%) were unable to carry out any flexibility or mobility testsdue to physical limitations. The number of refusals was specific toeach test: strength/endurance of lower limbs, 21 older adults;mobility/flexibility, 16 older adults; and walking, four older adults.The mean time spent by the participant carrying out the physicalperformance tests is shown in Fig. 1.
Table 2 shows the survival analysis results with adjustedmodeling according to Cox. The data shows the associationbetween BMI and performance in lower limb strength/endurancetest. The underweight individuals took longer to complete the testin relation to older people with normal weight. The time spent byoverweight individuals to carry out the lower limb strength/endurance test did not differ significantly from adequate weight
Fig. 1. Mean time � standard deviation in carrying out physical performance tests.Lafaiete Coutinho, Brazil, 2011.
R.S. Ferreira et al. / Geriatric Nursing 34 (2013) 465e468 467
participants (Fig. 2). No associations were observed between BMIand performance in mobility/flexibility tests or walking.
Fig. 2. Accumulated proportion of older adults, according to time taken to completethe “chair stand” test, according to nutritional status. Lafaiete Coutinho, Brazil, 2011.
Discussion
The results in the present study show that BMI was not associ-ated with performance in walking and mobility/flexibility tests.However, underweight individuals had the worst performance,independent of gender and age, in the lower limb strength/endur-ance test, when compared with individuals of adequate weight.
The relationship between underweight and lower limbstrength/endurance verified in the present study diverges fromobservations in other studies.10,11 In the study by Goins et al10
involving American Indians (�55 years of age), the higher BMIvalues were associated with the worst performance in the “chairstand” test. Data from the SABE/São Paulo Research11 carried outwith 2143 older adults did not show any association between thistest and nutritional status. However, it is worth stressing that thestudies adopted different BMI cut-off points to classify underweightand/or overweight, and the study by Goins et al10 involved youngerindividuals (55 years of age and older).
These findings suggest that the association between BMI andphysical performance can vary in different population groups andpossibly be mediated by exogenous characteristics. It is well-documented in epidemiologic studies that socioeconomic inequal-ities and/or socioeconomic development and income inequalityhave a negative result on health condition, including physicalperformance and nutritional status/BMI.1,3,9 We believe that thedifferences observed among the studies can be explained by thecharacteristics of the populations studied. The present study wascarried out in a city in northeast Brazil, a less developed region inthe country with high levels of poverty (47.8%) and low levels ofsocial inequality (Gini coefficient ¼ 0.35).20
Impairment of strength/endurance in underweight individualscan be explained by a lower volume of muscle mass in individuals
Table 2Cox multiple regression model coefficients between physical performance andnutritional status. Lafaiete Coutinho, Brazil, 2011.
Dependent variables Nutritional status badjusteda 95% IC p-value
Lower limb strength/endurance
Underweight 0.64 0.47e0.87 0.004Adequate 1Overweight 0.76 0.56e1.02 0.068
Mobility/flexibility Underweight 0.95 0.70e1.29 0.751Adequate 1Overweight 0.94 0.69e1.27 0.682
Walking Underweight 0.98 0.73e1.31 0.905Adequate 1Overweight 1.09 0.81e1.45 0.580
a Controlled for gender and age.
with this nutritional disorder. The fact that BMI is highly correlatedwith fat-free mass in older adults, including oldest old21 suggeststhat lower BMI values can be associated with progressive loss ofmuscle mass, strength and quality, a condition known as sarcope-nia.22 It is important to know that due to reduction of height withadvancing age, BMI may have different meaning in young adultsand older adults.21 The best BMI cut-off points to identify under-weight and/or overweight in older adults is still controversial.1,2,4 Inthe present study we used the BMI cut-off point adopted by theBrazilian system of surveillance for food and nutrition (Portugueseacronym, SISVAN),19 recommended by respected health organiza-tions recognized worldwide.18
It is a known fact that adequate nutrition is essential to keephealthy and that changes to BMI have been associated with sarco-penia in old age.23 Literature has demonstrated thatmusculoskeletaldysfunctions are predictive of functional limitations and physicalincapacity in older adults.24 Therefore, keeping a good nutritionalstatus is critical to preserve muscular strength and functionalcapacity, and therefore, the quality of life of these individuals.
It is important to stress the limitations and strong points of thestudy. The exclusion of individuals who were unable to completethe tests or who refused to perform them can be understood asa bias in the analysis; but as the distribution of BMI did not differamong these individuals (data not shown), we believe that thislimitation did not affect the conclusions of study. Although thecross-sectional design does not allowa causal link to be established,the results observed find support in literature. The physicalperformance tests used in this study are easy to apply, safe andvalid, and are widely published, especially in relation to pop-ulations of older adults.9,10 In the sameway, the use of BMI to assessthe nutritional status of individuals is justified by how easy it is toobtain weight and height data, low cost, little variation betweenevaluators and widespread use in epidemiological studies.10e12
The results from this study may contribute to the knowledge byhealth professionals of how different nutritional status can inter-fere with a status of fragility, as well as contribute to steer targets,objectives and conducts aiming at preventing incapacity. With theresults found, we can conclude that the negative impact of nutri-tional inadequacy over physical performance was specific to the
R.S. Ferreira et al. / Geriatric Nursing 34 (2013) 465e468468
test carried out. Underweight has proved to be a more limitingfactor of good physical function than overweight.
Acknowledgments
The researchwas partly funded by the UESB (UESB 117/2009 and011/2010). The authors thank the Municipal Secretariat of Health ofLafaiete Coutinho-BA and the elderly who participated in the study.
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